Intravenous tranexamic acid reduces blood transfusions in revision total hip arthroplasty: a meta-analysis

Efficacy of tranexamic acid versus placebo in reducing blood loss during burn excisional surgery: a multi-center, double-blind, parallel, randomized placebo-controlled clinical trial (TRANEX)

BACKGROUND

Despite an increase in knowledge, blood loss during burn excisional surgery remains a major challenge and is an independent predictor of mortality. During burn surgery, limited measures are available to control the bleeding. Increased fibrinolysis could be one of the contributing factors of blood loss during burn excisional surgery. Tranexamic acid inhibits the fibrinolytic response, and a small body of evidence shows positive effects of tranexamic acid on the volume of blood loss.

METHODS

The main objectives of this study are twofold, (1) to investigate whether tranexamic acid reduces blood loss and (2) to investigate the changes in coagulation after burn trauma and during burn excisional surgery. This study is a multicenter double-blind randomized clinical trial in patients scheduled for burn excisional surgery within the Dutch burn centers. All adult patients scheduled for burn surgery with an expected blood loss of ≥ 250 are eligible for inclusion in this study. The study is powered on a blood loss reduction of 25% in the intervention group. In total, 95 subjects will be included. The intervention group will receive 1500 mg tranexamic acid versus placebo in the other group. Primary endpoint is reduction of blood loss. Secondary endpoints include occurrence of fibrinolysis during surgery, graft take of the split skin graft, and differences in coagulation and blood clot formation.

DISCUSSION

This protocol of a randomized controlled trial aims to investigate the efficacy of tranexamic acid in reducing blood loss during burn excisional surgery. Furthermore, this study aims to clarify the coagulation status after burn trauma and during the surgical process.

TRIAL REGISTRATION

EudraCT: 2020-005405-10; ClinicalTrial.gov: NCT05507983 (retrospectively registered in August 2022, inclusion started in December 2021).

Tranexamic acid in total hip arthroplasty: An umbrella review on efficacy and safety

Purpose

This comprehensive review was conducted to assess the effects of tranexamic acid (TXA) on blood loss, venous thromboembolism (VTE) risk, and wound complications following total hip arthroplasty (THA). Additionally, it sought to evaluate the effects of various TXA dosages, modes of administration, and combinations with other antifibrinolytic drug.

Methods

In search of systematic reviews and meta-analyses on the use of TXA in THA patients, we searched extensively through databases including Scopus, the Cochrane Library, Embase, Medline, the Web of Science, PubMed, and Google Scholar. We discovered 23 meta-analyses covering 32,442 patients overall that fulfilled our study criteria, spanning the period from the creation of these databases until May 2023.

Results

This comprehensive review's meta-analyses, which together examined over 35,000 patients, repeatedly demonstrated how TXA administration during THA successfully lowers perioperative blood loss and the need for transfusions. TXA reduced total blood loss by an average of 151-370 ml, postoperative hemoglobin levels by 0.5-1.1 g/dL, and transfusion rates by 19-26% on average when compared to control groups. The information gathered did not indicate that using TXA significantly increased the risk of VTE or wound complications. When comparing different TXA doses, administration techniques, or its use in conjunction with other anti-fibrinolytic therapies, no discernible differences were found in terms of efficacy or safety outcomes.

Conclusion

The comprehensive review clearly indicates that TXA improves THA outcomes without increasing the risk of adverse events by lowering blood loss and the requirement for transfusions. This insightful information can help surgeons decide whether to use TXA during THA procedures.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Tranexamic acid dosage for spinal surgery: a meta-analysis

PURPOSE

We conducted this meta-analysis of randomized controlled trials (RCTs) to compare the efficacy of different doses of intravenous tranexamic acid (TXA) in spinal surgery.

METHODS

We searched relevant academic articles from PubMed, Embase, the Cochrane Library, and CNKI. Two reviewers independently selected studies, assessed quality, extracted data, and evaluated the risk of bias. RevMan 5.4 was used for data analysis.

RESULTS

Ten randomized controlled trials (RCTs) met the inclusion criteria and were identified, including 740 patients. According to the different dose regimens of intravenous TXA, the included studies' patients were divided into the high dose of intravenous TXA group and the low dose of intravenous TXA group. Compared with the low-dose group, the high-dose group can reduce the intraoperative blood loss (MD = - 100.87, 95% CI: [- 147.81, - 53.92], P < 0.0001). For the postoperative Hb and HCT, the high-dose group can separately maintain 4.54 g/dL (MD = 4.54, 95% CI: [2.08, 6.99], P = 0.003) and 1.27% (MD = 1.27, 95% CI: [0.59, 1.94], P = 0.0002). There were no statistically significant differences in total blood loss, preoperative Hb and HCT, operative time, and blood transfusion rate between the high-dose group and the low-dose group.

CONCLUSIONS

Based on the present meta-analysis, compared with the low-dose of intravenous TXA in spinal surgery, the high dose of intravenous TXA decreases the intraoperative blood loss and preserves higher postoperative Hb and HCT levels without increasing the operative time and blood transfusion rate.